MEDICAL STAFF BYLAWS MEDICAL. STAFF PEER REVIEW POLICY Saint Francis Hospital and Medical Center

Transcription

1 MEDICAL STAFF BLAWS MEDICAL STAFF PEER REVIEW POLIC Saint Francis Hospital and Mdical Cntr

2 Mdical Staff Pr Rviw Policy Purpos: To nsur that th hospital, through th activitis of its mdical staff, asssss th Ongoing Profssional Practic Evaluation of individuals grantd clinical privilgs and uss th rsults of such assssmnts to improv car and, whn ncssary, prform Focusd Profssional Practic Evaluation. Goals: 1 Monitor and valuat th ongoing profssional practic of individual practitionrs with clinical privilgs; 2 Crat a cultur with a positiv approach to pr rviw by rcognizing physician xcllnc as wll as idntifying improvmnt opportunitis 3 Prform focusd profssional practic valuation whn potntial physician improvmnt opportunitis ar idntifid 4 Promot fficint us of physician and quality staff rsourcs 5 Provid accurat and timly prformanc data for physician fdback, Ongoing and Focusd Profssional Practic Evaluation and rappointmnt. 6 Assur that th procss for pr rviw is clarly dfind, fair, dfnsibl, timly and usful. Dfinitions: Pr rviw Pr rviw is th valuation of an individual practitionr s profssional prformanc and includs th idntification of opportunitis to improv car. Pr rviw diffrs from othr quality improvmnt procsss in that it valuats th strngths and waknsss of an individual practitionr s prformanc, rathr than appraising th quality of car rndrd by a group of profssionals or a systm. Consistnt with Chaptr 368a of th Conncticut Gnral Statuts, Pr Rviw shall also man th procdur for valuation by halth car profssionals of th quality and fficacy of srvics ordrd or prformd by othr halth car profssionals, including practic analysis, inpatint hospital and xtndd car facility utilization rviw, mdical audit, ambulatory car rviw, and claims rviw. Pr rviw is conductd using multipl sourcs of information including: 1) th rviw of individual cass, 2) th rviw of aggrgat data for complianc with gnral ruls of th mdical staff and, 3) clinical standards and us of rats in comparison with stablishd bnchmarks or norms. Th individual s valuation is basd on gnrally rcognizd standards of car. Through this procss, practitionrs rciv fdback for prsonal improvmnt or confirmation of prsonal achivmnt rlatd to th ffctivnss of thir profssional practic as dfind by th six Joint Commission Gnral Comptncis dscribd blow: Patint Car: Practitionrs ar xpctd to provid patint car that is compassionat, appropriat, and ffctiv for th promotion of halth, prvntion of illnss, tratmnt of disas and at th nd of lif Mdical Knowldg: Practitionrs ar xpctd to dmonstrat knowldg of stablishd and volving biomdical, clinical and social scincs, and th application of thir knowldg to patint car and th ducation of othrs Practic Basd Larning and Improvmnt: Practitionrs ar xpctd to b abl to us scintific vidnc and mthods to invstigat, valuat, and improv patint car Intrprsonal and Communication Skills: Practitionrs ar xpctd to dmonstrat intrprsonal and communication skills that nabl thm to stablish and maintain profssional rlationships with patints, familis, and othr mmbrs of halth car tams

3 Profssionalism: Practitionrs ar xpctd to dmonstrat bhaviors that rflct a commitmnt to continuous profssional dvlopmnt, thical practic, an undrstanding and snsitivity to divrsity, and a rsponsibl attitud toward thir patints, thir profssion, and socity Systms Basd Practic: Practitionrs ar xpctd to dmonstrat both an undrstanding of th contxts and systms in which halth car is providd, and th ability to apply this knowldg to improv and optimiz halthcar Ths comptncis ar furthr laboratd in th Mdical Staff Expctations for Physicians (Attachmnt A). Pr A pr is an individual practicing in th sam profssion and who has xprtis in th appropriat subjct mattr. Th lvl of subjct mattr xprtis rquird to provid maningful valuation of a practitionr s prformanc will dtrmin what practicing in th sam profssion mans on a cas-by-cas basis. For xampl, for quality issus rlatd to gnral mdical car, a physician (MD or DO) may rviw th car of anothr physician. For spcialty-spcific clinical issus, such as valuating th tchniqu of a spcializd surgical procdur, a pr is an individual who is wll-traind and comptnt in that surgical spcialty. Pr Rviw Body Th pr rviw body dsignatd to prform th initial rviw by th Mdical Excutiv Committ or its dsign will dtrmin th dgr of subjct mattr xprtis rquird for a providr to b considrd a pr for all pr rviws prformd by or on bhalf of th hospital. Th initial pr rviw body will b th Mdical Staff Quality Committ (MSQC) as dscribd in th MSQC Chartr (Attachmnt B) unlss othrwis dsignatd for spcific circumstancs by th MEC. Pr Rviw may b carrid out by any committ that has bn stablishd undr th mdical staff bylaws, whn ngagd in pr rviw as dirctd by th MEC, or activitis of any board or committ rviwing profssional qualifications of staff or prospctiv staff. Ongoing Profssional Practic Evaluation (OPPE) Th routin monitoring and valuation of currnt comptncy for currnt mdical staff. Ths activitis compris th majority of th functions of th ongoing pr rviw procss and th us of data for rappointmnt. Focusd Profssional Practic Evaluation (FPPE) Th stablishmnt of currnt comptncy for nw mdical staff mmbrs, nw privilgs and or concrns from OPPE. Ths activitis compris what is typically calld proctoring or focusd rviw dpnding on th natur of th circumstancs. Conflict of Intrst A mmbr of th mdical staff rqustd to prform pr rviw may hav a conflict of intrst if h/sh may not b abl to rndr an unbiasd opinion. An absolut conflict of intrst would rsult if th physician is th providr undr rviw or is a first dgr rlativ. Rlativ conflicts of intrst ar ithr du to a providr s involvmnt in th patint s car not rlatd to th issus undr rviw or bcaus of a rlationship with th physician involvd as a dirct comptitor, partnr or ky rfrral sourc. It is th obligation of th individual rviwr to disclos to th pr rviw committ th potntial conflict. It is th rsponsibility of th pr rviw body to dtrmin on a cas by cas basis if a rlativ conflict is substantial nough to prvnt th individual from participating. Whn a potntial rlativ conflict is idntifid, th MSQC chair will b informd in advanc and mak th dtrmination if a substantial conflict xists. Whn ithr an absolut or substantial rlativ conflict is dtrmind to xist, th individual may not participat or b prsnt during pr rviw body discussions or dcisions othr than to provid spcific information rqustd as dscribd in th Pr Rviw Procss (Attachmnt C).

4 Policy: 1. pr rviw information is privilgd and confidntial in accordanc with mdical staff and hospital bylaws, stat and fdral laws, and rgulations prtaining to confidntiality and nondiscovrability. 2. Th individual practitionr will rciv providr-spcific fdback on a routin basis. 3. Th mdical staff will us th providr-spcific pr rviw rsults in making its rcommndations to th hospital rgarding th crdntialing and privilging procss and, as appropriat, in its prformanc improvmnt activitis. 4. Th hospital will kp providr-spcific pr rviw and othr quality information concrning a practitionr in scur, lockd fils in crdntialing and quality dpartmnts. Providr-spcific pr rviw information consists of information rlatd to: prformanc data for all dimnsions of prformanc masurd for that individual physician, th individual physician s rol in sntinl vnts, significant incidnts or nar misss, corrspondnc to th physician rgarding commndations, commnts rgarding practic prformanc, or corrctiv action. 5. Only th final dtrminations of th MSQC/MSQOC and any subsqunt actions ar considrd part of an individual providr s quality fil. Any writtn or lctronic documnts rlatd to th rviw procss othr than th final committ dcisions shall b considrd working nots of th committ and shall b dstroyd by policy aftr th committ dcision has bn mad. Working nots includ potntial issus idntifid by hospital staff, prliminary cas rating, qustions and nots and th physician rviwrs and rqusts for information from th involvd physicians and any writtn rsponss to th committ. 6. Pr rviw information in th individual providr quality fil is availabl only to authorizd individuals who hav a lgitimat nd to know this information basd upon thir rsponsibilitis as a mdical staff ladr or hospital mploy. Howvr, thy shall hav accss to th information only to th xtnt ncssary to carry out thir assignd rsponsibilitis. Th VPMA will assur that only authorizd individuals hav accss to individual providr quality fils and that th fils ar rviwd undr th suprvision of th Coordinator of Mdical Staff Srvics or dsign. Only th following individuals shall hav accss to providr-spcific pr rviw information and only for purposs of quality improvmnt: Th spcific providr; Th Prsidnt of th Mdical Staff for purposs of considring corrctiv action; Mdical staff dpartmnt chairs (for mmbrs of thir dpartmnts only) to conduct OPPE; Mmbrs of th mdical xcutiv committ, crdntials committ and mdical staff srvics profssionals for purposs of considring rappointmnt or corrction action. VPMA, Chif Quality Officr, Quality Dirctor and quality staff supporting th pr rviw procss; Individuals survying for accrditing bodis with appropriat jurisdiction,.g. Joint Commission or stat/fdral rgulatory bodis; and Th hospital CEO whn information is ndd to for th CEO s involvmnt in th procss of immdiat formal corrctiv action for purposs of summary suspnsion as dfind by th mdical staff bylaws. 7. No copis of pr rviw documnts will b cratd and distributd unlss authorizd by mdical staff policy or bylaws, th MEC, th Board or by mutual agrmnt btwn th Prsidnt of th Mdical Staff and th VPMA for purposs of dlibrations rgarding corrctiv action on spcific cass. Circumstancs rquiring pr rviw: Pr rviw is conductd on an ongoing basis and rportd to th appropriat committ for rviw and action. Th procdurs for conducting pr rviw for individual cass and for aggrgat prformanc masurs is dscribd in Attachmnts B and C. In th vnt a dcision is mad by th Board of Dirctors to invstigat a practitionr s prformanc or circumstancs warrant th valuation of on or mor providrs with privilgs, th mdical xcutiv

5 committ or its dsign shall appoint a panl of appropriat mdical profssionals to prform th ncssary pr rviw activitis as dscribd in th Mdical Staff Bylaws. Circumstancs rquiring xtrnal pr rviw: Eithr th MSQOC, MSQC, MEC or th Board of Dirctors will mak dtrminations on th nd for xtrnal pr rviw. No practitionr can rquir th hospital to obtain xtrnal pr rviw if it is not dmd appropriat by th MEC, MSQC or th Board of Dirctors. Circumstancs rquiring xtrnal pr rviw may includ but ar not ncssarily limitd to: Litigation - whn daling with th potntial for a lawsuit. Ambiguity - whn daling with vagu or conflicting rcommndations from intrnal rviwrs or mdical staff committs and conclusions from this rviw will dirctly impact a practitionr s mmbrship or privilgs. Lack of intrnal xprtis Whn no on on th mdical staff has adquat xprtis in th spcialty undr rviw; or whn th only practitionrs on th mdical staff with that xprtis ar dtrmind to hav a conflict of intrst rgarding th practitionr undr rviw as dscrib abov. Extrnal pr rviw will tak plac if this potntial for conflict of intrst cannot b appropriatly rsolvd by th mdical xcutiv committ or govrning board. Miscllanous issus - whn th mdical staff nds an xprt witnss for a fair haring, for valuation of a crdntial fil, or for assistanc in dvloping a bnchmark for quality monitoring. In addition, th mdical xcutiv committ or govrning board may rquir xtrnal pr rviw in any circumstancs dmd appropriat by ithr of ths bodis. Participants in th rviw procss: Participants in th rviw procss will b slctd according to th mdical staff policis and procdurs. Th work of all practitionrs grantd privilgs will b rviwd through th pr rviw procss. Clinical support staff will participat in th rviw procss if dmd appropriat. Additional support staff will participat if such participation is includd in thir job rsponsibilitis. Th pr rviw body will considr th viws of th prson whos car is undr rviw prior to making a final dtrmination rgarding th car providd by that individual providing that individual rsponds in th timfram outlind in Attachmnt C. In th vnt of a conflict of intrst or circumstancs that would suggst a biasd rviw byond that dscribd abov, th MSQC, th MSQOC or th MEC will rplac, appoint or dtrmin who will participat in th procss so that bias dos not intrfr in th dcision-making procss. Mdical Rviw Committ Mdical Rviw Committ shall includ any committ of th hospital stablishd pursuant to this or any part of th mdical staff bylaws, or any ntity prmittd pursuant to stat law, ngaging in pr rviw to gathr and rviw information rlating to th car and tratmnt of patints for th purposs of any of th following: valuating and improving th quality of halth car rndrd; rducing morbidity and mortality; or stablishing and nforcing guidlins dsignd to kp within rasonabl bounds th cost of halth car. Mdical Rviw Committ shall also man any hospital board or committ rviwing th profssional qualifications or activitis of its mdical staff or applicants for admission to th mdical staff. Individual Cas Rviw Pr rviw will b conductd by th mdical staff in a timly mannr. Th goal is for routin cass to b compltd within 90 days from th dat th chart is rviwd by th Dpartmnt of Quality Outcoms staff and complx cass to b compltd within 120 days. Excptions may occur basd on cas complxity or rviwr availability. Th timlins for this procss ar dscribd in Attachmnt B. Th rating systm for dtrmining rsults of individual cas rviws is dscribd in th Cas Rviw Rating Form (Attachmnt D). Rat and Rul Indicator Data Evaluation Th valuation of aggrgat physician prformanc masurs via ithr rat or rul indicators will b conductd on an ongoing basis by th MSQC/MSQOC or its dsign is dscribd in Attachmnt B.

6 Slction of Physician Prformanc Masurs Masurs of physician prformanc will b slctd to rflct th six Gnral Comptncis and will utiliz multipl sourcs of data dscribd in th Mdical Staff Indicator List in Attachmnt E. Thrsholds for Focusd Profssional Practic Evaluation: If th rsults of Ongoing Profssional Practic Evaluation indicat a potntial issu with physician prformanc, th MSQC/MSQOC may initiat a focusd valuation to dtrmin if thr is problm with currnt comptncy of th physician for ithr spcific privilgs or for mor global dimnsions of prformanc. Ths potntial issus may b th rsult of individual cas rviw or rul or rat indicators. Th thrsholds for Focusd Profssional Practic Evaluation ar dscribd in th accptabl targts for th mdical staff indicators in Attachmnt E. Howvr, a singl grgious cas may initiat a focusd rviw by th MSQC/MSQOC. Ovrsight and Rporting Dirct ovrsight of th pr rviw procss is dlgatd by th MEC to th MSQOC. Th rsponsibilitis of th MSQOC rlatd to pr rviw ar dscribd in th MSQOC chartr (Attachmnt B). Th MSQOC will rport to th Board of Dirctors through th MEC at last quartrly. Statutory Authority This policy is basd on th statutory authority of th Halth Car Quality Improvmnt Act of U.S.C , t sq. and Chaptr 368a of th Conncticut Gnral Statuts. minuts, rports, rcommndations, communications and actions mad or takn pursuant to this policy ar dmd to b covrd by such provisions of fdral and stat law providing protction to pr rviw rlatd activitis. Documnts, including minuts and cas rviw matrials, prpard in connction with this policy should b labld with languag consistnt with th following: Statmnt of Confidntiality Th procdings of a mdical rviw committ conducting pr rviw shall b, at a minimum, subjct to all of th confidntiality and immunity provisions as providd in Chaptr 368a of th Conncticut Gnral Statuts. Thr shall b no disclosur of pr rviw information that would caus th pr rviw protctions of th stat law to b jopardizd. Attachmnt List Attachmnt A: Mdical Staff Expctations for Gnral Comptncis Attachmnt B: MSQC Chartrs Attachmnt C: Cas Rviw Procss Attachmnt D: Cas Rviw Rating Form Attachmnt E: Mdical Staff Indicators and Targts Attachmnt F: MSQOC Chartr Attachmnt G: Data Trnds Council Chartr

7 Attachmnt A Expctations of Attnding Physicians Grantd Privilgs at Saint Francis Hospital and Mdical Cntr This documnt dscribs th xpctations that physicians hav of ach othr as mmbrs of our mdical staff basd on th ACGME/Joint Commission physician Gnral Comptncis framwork. Th xpctations dscribd blow rflct currnt mdical staff bylaws, policis and procdurs and organizational policis. This documnt is dsignd to bring togthr th most important issus found in thos documnts and ky concpts rflcting our mdical staff s cultur and vision. Mdical staff ladrs will work to improv individual and aggrgat mdical staff prformanc through providing appropriat masurmnt of ths xpctations that provids positiv and constructiv fdback so ach physician has th opportunity to grow and dvlop in his or hr capabilitis to provid outstanding patint car and valuabl contributions to our hospital. Patint Car: Practitionrs ar xpctd to provid patint car that is compassionat, appropriat, and ffctiv for th promotion of halth, prvntion of illnss, tratmnt of disas and at th nd of lif as vidncd by th following: 1 Provid ffctiv patint car that consistntly mts or xcds mdical staff standards of car as dfind by comparativ outcom data, mdical litratur and rsults of pr rviw activitis. 2 Plan and provid appropriat patint managmnt basd on clinical patint information, patint prfrncs, currnt indications, availabl scintific vidnc and sound clinical judgmnt. 3 Assur that ach patint is valuatd by a physician as dfind in th bylaws, ruls and rgulations and documnt findings in th mdical rcord at that tim. 4 Dmonstrat caring and rspctful bhaviors whn intracting with patints and thir familis 5 Provid for patint comfort by managing acut and chronic pain according to mdically appropriat standards. 6 Counsl and ducat patints and thir familis 7 Cooprat with hospital fforts to implmnt mthods to systmatically nhanc disas prvntion. 8 If applicabl, suprvis rsidnts, studnts and allid halth profssionals to assur patints rciv th highst quality of car. Mdical Knowldg: Practitionrs ar xpctd to dmonstrat knowldg of stablishd and volving biomdical, clinical and social scincs, and th application of thir knowldg to patint car and th ducation of othrs as vidncd by th following:. 1 Us vidnc-basd guidlins whn availabl, as rcommndd by th appropriat spcialty, in slcting th most ffctiv and appropriat approachs to diagnosis and tratmnt. 2 Maintain ongoing mdical ducation as appropriat for ach spcialty and rgulatory bodis. 3 Dmonstrat appropriat tchnical skills and mdical knowldg using mdical simulation tchnology whr appropriat. Practic Basd Larning and Improvmnt: Practitionrs ar xpctd to b abl to us scintific vidnc and mthods to invstigat, valuat, and improv patint car as vidncd by th following: 1 Rgularly rviw your individual and spcialty data for all gnral comptncis and us th data for slf improvmnt of patint car. 2 Rspond in th spirit of continuous improvmnt whn contactd rgarding concrns about patint car. 3 Us hospital information tchnology to manag information and accss on-lin mdical information. 4 Facilitat th larning of studnts, trains and othr halth car profssionals

8 Attachmnt A Intrprsonal and Communication Skills: Practitionrs ar xpctd to dmonstrat intrprsonal and communication skills that nabl thm to stablish and maintain profssional rlationships with patints, familis, and othr mmbrs of halth car tams as vidncd by th following: 1 Communicat ffctivly with physicians, othr cargivrs, patints and familis to nsur accurat transfr of information through appropriat oral and writtn mthods according to hospital policis. 2 Rqust inpatint consultations by providing adquat communication with th consultant including a clar rason for consultation and dirct physician-to-physician contact for urgnt or mrgnt rqusts. 3 Maintain mdical rcords consistnt with th mdical staff bylaws, ruls, rgulations and policis. 4 Work ffctivly with othrs as a mmbr or ladr of a halth car tam or othr profssional group 5 Maintain patint satisfaction with physician car. Profssionalism: Practitionrs ar xpctd to dmonstrat bhaviors that rflct a commitmnt to continuous profssional dvlopmnt, thical practic, an undrstanding and snsitivity to divrsity, and a rsponsibl attitud toward thir patints, thir profssion, and socity as vidncd by th following: 1 Act in a profssional, rspctful mannr at all tims and adhr to th Mdical Staff Standards of Profssional COnduct 2 Rspond promptly to rqusts for patint car nds. 3 Addrss disagrmnts in a constructiv, rspctful mannr away from patints or non-involvd cargivrs. 4 Participat in mrgncy call as dfind in th bylaws, ruls and rgulations 5 Follow thical principls prtaining to provision or withholding of clinical car, confidntiality of patint information, informd consnt, and discussion of unanticipatd advrs outcoms. 6 Utiliz snsitivity and rsponsivnss to cultur, ag, gndr, and disabilitis for patints and staff. 7 Mak positiv contributions to th mdical staff by participating activly in mdical staff functions, srving whn rqustd and by rsponding in a timly mannr whn input is rqustd. Systms Basd Practic: Practitionrs ar xpctd to dmonstrat both an undrstanding of th contxts and systms in which halth car is providd, and th ability to apply this knowldg to improv and optimiz halthcar as vidncd by th following: 1 Comply with hospital fforts and policis to maintain a patint safty cultur, rduc mdical rrors, mt national patint safty goals and improv quality. 2 Follow nationally rcognizd rcommndations rgarding infction control procdurs and prcautions whn participating in patint car. 3 Ensur timly and continuous car of patints by clar idntification of covring physicians and by availability through appropriat and timly lctronic communication systms. 4 Provid quality patint car that is cost ffctiv by cooprating with fforts to appropriatly manag th us of valuabl patint car rsourcs. 5 Cooprat with guidlins for appropriat hospital admission, lvl of car transfr, and timly discharg to outpatint managmnt whn mdically appropriat. 6 Advocat for quality patint car and assist patints in daling with systm complxitis.

9 Mdical Staff Quality Ovrsight Committ (MSQOC) Chartr Goals To provid ovrsight for th policis, procdurs and rsults of physician prformanc as prformd by th mdical staff quality committs to achiv th following goals: 1 Improv patint outcoms by pursuing and maintaining xcllnc in physician prformanc on an individual and aggrgat lvl 2 Crat a cultur with a positiv approach to physician pr rviw through assuring th us of consistnt and fair procsss 3 Promot fficint us of physician and quality staff rsourcs 4 Assur that accurat and timly prformanc data is availabl for physician fdback, Ongoing and Focusd Profssional Practic Evaluation and rappointmnt. 5 Support mdical staff ducational goals to improv patint car 6 Provid a link with th hospital prformanc improvmnt structur to assur rsponsivnss to systm improvmnt opportunitis idntifid by th mdical staff Scop Th MSQOC will b rsponsibl for ovrsing th accountability and ffctivnss of th individual Multi-spcialty Quality Committs (MSQC) and for dvloping systmatic approachs to valuating and improving physician prformanc in th Gnral Comptncis as dscribd th Pr Rviw Policy and Mdical Staff Expctations. Th MSQOC will also act as a pr rviw committ for spcific cass as dscribd blow. Rsponsibilitis 1. Cas Rviw Rcommnd to th MEC gnral policis and procdurs for MSQC prformanc of individual cas rviw and xtrnal pr rviw. Rviw and approv MSQC spcific approachs for individual cas rviw to assur that thy comply with gnral policis and rgulatory rquirmnts. Dfin standardizd tools for cas rviw to b usd by all MSQCs prforming pr rviw. Provid ovrsight to assur all MSQCs ar conducting and rporting th rsults of pr rviw on a systmatic and timly basis. Rviw and approv spcific Rviw indicator critria basd on th rcommndations of th all MSQCs and th dpartmnt chairs. Prform pr rviw of cass rfrrd to th MSQOC for th following rasons: o Difficult or complx issus byond th capabilitis of th MSQC, o Substantial conflict of intrst that would prclud ffctiv MSQC rviw 2. Aggrgat o Masurs Potntial of nd Physician for xtrnal Prformanc pr rviw. Rviw and approv systm wid and campus spcific rat indicators including bnchmarks or targts basd on th rcommndations of th appropriat spcialtis Rcommnd prospctiv valuations of bst practics and us of vidnc basd mdicin to idntify opportunitis for improvmnt and th pursuit of xcllnc Assur rgular rviw is prformd of aggrgatd rsults of rat indicators for pattrns, trnds and outlir status Assur that pattrns and trnds ar addrssd by th MSQCs to improv ithr individual or aggrgat physician prformanc 3. Improvmnt Opportunitis Addrssing improvmnt opportunitis will b th rol of MSQC, th mdical staff ladrs and th MEC. Th rol of th MSQOC is to assur whn opportunitis for physician improvmnt ar idntifid, th ladrship follows through with th procss. This will b accomplishd through th

10 MSQC Chair rporting to th MSQOC rgularly rgarding rcommndations to improv car and any situations whr furthr rcommndations ar mad. 4. Prformanc Improvmnt Systm Managmnt Dfin mchanisms for rporting th rsults of physician prformanc valuation to th MEC and th Board Dvlop ovrall stratgis and policis for th us of lctronic and risk adjustd data in physician prformanc valuation In coordination with th Crdntials Committ and th MEC, dfin th appropriat contnt and format for physician prformanc fdback rports Dtrmin support ndd to implmnt and sustain th procss and mak rcommndations to th administration and MEC accordingly. At last annually rviw th indicators, scrn tools and rfrral systms for ffctivnss and rcommnd changs to th MEC. 5. Ovrsight of Othr Mdical Staff Physician Prformanc Evaluation Committs Although th vast majority of initial rviw of individual cass, along with rul and rat indicator rsults, will b prformd by th MSQCs, som mdical staff dpartmnts or committs will continu to prform som of ths functions ithr as a quality control mchanism or as a multi-disciplinary ducational procss. Such discussions will b considrd part of th mdical staff quality function and ar protctd from discovry as long as th appropriat policis and procdurs of th MSQOC ar followd. Ths dpartmnts or committs will rfr to th Dpartmnt of Quality and Outcoms any cas mting mdical staff Rviw Indicator critria for initiation of th cas rviw procss by th appropriat MSQC. In addition, spcific dpartmnts or committs will prform th initial rviw of Rat and Rul indicator data rlativ to thir ara of xprtis and may addrss pattrns and trnds and rport thir findings to th MSQOC as indicatd blow. Imag Basd Spcialtis (Pathology, Radiology, Cardiac Imags, Vascular Intrvntion): Imag Basd Spcialtis will prform routin quality rviws of diagnostic imag intrprtation by physicians (.g. surgical pathology or cytology slids, radiologic imags) with th aggrgat findings rportd to MSQOC as ithr Rul or Rat Indicators. Cass with misintrprtations or missd findings rsulting in significant chang in tratmnt, or significant advrs outcoms potntially rlatd to physician car, as dfind by Rviw indicators, will b rfrrd to th quality offic to initiat th MSQC pr rviw procss. Trauma: Th Trauma Committ will continu to prform its functions undr th rquird ACS standards. Cass rsulting in significant advrs outcoms potntially rlatd to physician car as dfind by Rviw indicators will b rfrrd to th quality offic to initiat th MPRC pr rviw procss. Emrgncy Dpartmnt: Th Emrgncy Dpartmnt may prform rviw of spcific procsss and outcoms as appropriat for dpartmntal prformanc improvmnt and ducation at th individual campus sits. For thos indicators dtrmind by th MEC as rportabl to th mdical staff, th dpartmnt will rport th rsults, as ithr Rul or Rat Indicators, to th MSQOC. Cass rsulting in significant advrs outcoms potntially rlatd to physician car as, dfind by Rviw indicators, will b rfrrd to th quality offic to initiat th MPRC pr rviw procss. \ Ansthsia Dpartmnt: Th Ansthsia Dpartmnt may prform rviw of th procsss and outcoms of car providd in th Ansthsia Dpartmnt. For thos indicators dtrmind by th MEC as rportabl to th mdical staff, th dpartmnt will rport th rsults, as ithr Rul or Rat Indicators, to th MSQOC. Cass rsulting in significant advrs outcoms potntially rlatd to physician car as, dfind by Rviw indicators, will b rfrrd to th quality offic to initiat th MSQC pr rviw procss. Hoffman Hart and Vascular Institut: Th Hoffman Hart and Vascular Institut may prform rviw of th procsss and outcoms of car providd in th Hoffman Hart and Vascular Institut. For thos indicators dtrmind by th MEC as rportabl to th mdical staff, th Institut will rport th rsults, as ithr Rul or Rat Indicators, to th MSQC. Cass rsulting in significant advrs

11 outcoms potntially rlatd to physician car as, dfind by Rviw indicators, will b rfrrd to th Dpartmnt of Quality and Outcoms to initiat th MSQC pr rviw procss. Mmbrship Th MSQOC will b comprisd of th chairs ach MSQC, and four (4) additional appointd mmbrs by th Prsidnt of th Mdical Staff to crat a balancd rprsntation from th mdical staff. Th following ar x-officio mmbrs without vot: th Prsidnt of th Mdical Staff, th CMO, th CNO, th Dirctor for Quality Outcoms, and th Chif Quality Officr. MSQC chair mmbrs will srv trms coinciding with thir trm as MSQC chair. Appointd mmbrs will srv for a thr yar trm xcpt for initial committ mmbrs. Th initial committ will hav staggrd trms with a third of th mmbrs assignd initial trms of on yar, a third assignd initial trms of two yars and a third assignd initial trms of thr yars. Appointd mmbrs may srv an unlimitd numbr of conscutiv trms. Th Chair of th MSQOC will b appointd by th Mdical Staff Prsidnt with approval by th MEC from committ mmbrs who hav srvd for mor than on yar (xcpt for th first committ chair). Th Chair will b a voting mmbr of th MEC. In addition to th abov mmbrs, ky clinical administrativ rprsntativs and support staff mutually agrd upon btwn th Mdical Staff and Administration may attnd th MSQOC mtings. Committ mmbrs will b xpctd to attnd at last two thirds of th committ mtings ovr a twlv month priod to maintain mmbrship (no dsigns allowd). Committ mmbrs will b xpctd to participat in appropriat ducational programs providd by th Hospital or Mdical Staff to incras thir knowldg and skills in prforming th Committ s rsponsibilitis. Mtings and Rporting Th MSQOC is a subcommitt of th MEC. Th MSQOC will mt at last 10 tims pr yar. Th MSQC will rport at last 10 tims pr yar to th MSQOC/ MEC. No changs can b mad to th MSQOC chartr and policis without approval of th MEC.

12 Mdicin Multi-spcialty Quality Committ (MSQC) Chartr Goals Establishmnt of a multi-spcialty committ for improving physician prformanc on an individual and aggrgat lvl to accomplish th following: 1 Improv patint outcoms by pursuing and maintaining xcllnc in physician prformanc 2 Crat a cultur with a positiv approach to physician pr rviw 3 Promot fficint us of physician and quality staff rsourcs 4 Assist in providing accurat and timly prformanc data for physician fdback and rappointmnt 5 Support mdical staff ducational goals to improv patint car Scop Th MSQC will b rsponsibl for valuating and improving physician prformanc for th mdical spcialty aras undr its scop undr th ovrsight of th Mdical Staff Quality Ovrsight Committ (MSQOC) for th six Comptncis as dscribd th Pr Rviw Policy and Mdical Staff Expctations.: Th following spcialty aras ar undr th scop of th Mdicin MSQC: Intrnal Mdicin Family Mdicin Cardiology Gastrontrology Hospital Mdicin Emrgncy Mdicin Critical Car Mdicin/Pulmonary Infctious Disas Nurology Rhumatology Nphrology Drmatology Radiology Oncology/Hmatology Radiation Oncology Psychiatry Griatric Mdicin Endocrinology Physiatry Th following aras ar considrd outsid th Committ s scop: o Individual physician bhavior incidnts will b th rsponsibility of th Dpartmnt Chair. o Routin concurrnt aspcts of physician rsourc us will b managd through th Utilization Rviw procss. Pattrns and trnds data will b initially addrssd by th MSQC. o Policis rquiring mdical staff approval for Blood Us will b rfrrd to th MEC for approval. Th MSQC will prform pr rviw rlating to th us of blood or blood products. o Formulary and mdication policy issus rquiring mdical staff approval will b addrssd by th Drug Thrapy Managmnt Committ and rfrrd to th MEC for approval. Th MSQC will prform pr rviw rlating to th us of mdications rlatd to physician car. o Halth Information Managmnt systms issus will b addrssd and issus rlatd to physician complianc rlatd to documntation critria and rcord compltion will b addrssd by th Mdical Rcords Committ. Physician prformanc indicators for HIM issus will b dtrmind by th MEC. o Crdntialing and privilging is th rsponsibility of th Mdical Staff Dpartmnt Chair and th Crdntials Committ. Rsponsibilitis

13 Evaluation of Individual Cass Initial rviw of all cass of sufficint complxity of managmnt or sriousnss of outcom rquiring physician pr rviw basd on cass idntifid by Rviw indicators, ongoing dpartmntal audits or through rfrrals to th Quality and Outcoms staff for th spcific clinical conditions as dfind in th scop of th committ. Obtain rviws and rcommndations from spcialists on th mdical staff or othr MSQCs whn rquird. Communicat with th physician involvd with th cas to obtain input prior to making dtrminations whn opportunitis for improvmnt may xist. Mak rcommndations rgarding individual or Hospital Systm PI opportunitis for improvmnt basd on individual cas rviw. Evaluation of Rat and Rul Indicators Prform rgular rviw of advrs outlirs from aggrgatd rsults of Rul indicators and of advrs pattrns, trnds and outlir status for Rat indicators rlvant to all dimnsions of physician prformanc for th spcific clinical conditions as dfind within th scop of th committ. Th purpos of this rviw is to dtrmin if additional analysis or focus studis ar ndd. This function may b dlgatd to an individual mmbr of th committ or to a subcommitt. Idntify individual or Hospital PI opportunitis for improvmnt and dtrmin if additional analysis or focus studis ar ndd. Ovrsight of Othr Mdical Staff Physician Prformanc Evaluation Committs Th vast majority of initial rviw of individual cass, along with rul and rat indicator rsults, will b prformd by th appropriat MSQC. mdical staff dpartmnts that wish to mt for purpos of M & M rviw for ducational purposs may also do so if thy wish. Such discussions will b considrd part of th mdical staff quality function and ar protctd from discovry as long as th appropriat policis and procdurs ar followd. Howvr, som mdical staff dpartmnts or committs will continu to prform spcific functions ithr as a quality control mchanism or to rviw of spcific procsss and outcoms as appropriat for dpartmntal prformanc improvmnt and ducation. Th MSQOC will hav ovrsight of th procss usd to prform this rviw and th indicators slctd by th spcialty. For Rul or Rat indicators dtrmind by th MEC as rportabl to th mdical staff, th dpartmnt will rport th rsults to th MSQOC. Th dpartmnt or th group will rfr to th quality offic any cas mting mdical staff Rviw indicator critria for initiation of th cas rviw procss by th appropriat MSQC. Th following aras will prform this function as dscribd blow: Pathology: Th Pathology Dpartmnt will prform rviw of surgical pathology or cytology slids intrprtd by pathologists with th aggrgat findings rportd to MSQOC. Cass rsulting in significant chang in tratmnt, or significant advrs outcoms potntially rlatd to physician car, as dfind by Rviw indicators du to misintrprtations or missd findings will b rfrrd to th quality offic to initiat th MSQC pr rviw procss. Radiology: Th Radiology Dpartmnt ( including Diagnostic imaging, Intrvntional Radiology) will prform rviw of radiologic imags intrprtd by radiologists with th aggrgat findings rportd to MSQOC. Cass rsulting in significant chang in tratmnt, or significant advrs outcoms potntially rlatd to physician car, as dfind by Rviw indicators du to misintrprtations or missd findings will b rfrrd to th quality offic to initiat th MSQOC pr rviw procss. Emrgncy Dpartmnt: Th Emrgncy Dpartmnt may prform rviw of spcific procsss and outcoms as appropriat for dpartmntal prformanc improvmnt and ducation. Cass rsulting in significant advrs outcoms potntially rlatd to physician car as, dfind by Rviw indicators, will b rfrrd to th quality offic to initiat th MSQC pr rviw procss. Ansthsia: Th Ansthsia Dpartmnt may prform rviw of spcific procsss and outcoms as appropriat for dpartmntal prformanc improvmnt and ducation. Cass rsulting in significant advrs outcoms potntially rlatd to physician car as, dfind by Rviw indicators, will b rfrrd to th quality offic to initiat th MSQC pr rviw procss.

14 Trauma: Th Trauma Committ will continu to prform its functions undr th rquird ACS standards. Cass rsulting in significant advrs outcoms potntially rlatd to physician car as dfind by Rviw indicators will b rfrrd to th quality offic to initiat th MSQC pr rviw procss. Hoffman Hart and Vascular Institut: Th Hoffman Hart and Vascular Institut may prform rviw of spcific procsss and outcoms as appropriat for institut prformanc improvmnt and ducation. Cass rsulting in significant advrs outcoms potntially rlatd to physician car as, dfind by Rviw indicators, will b rfrrd to th quality offic to initiat th MSQC pr rviw procss. Improvmnt Opportunitis Th rol of th MSQC is to assur whn opportunitis for improvmnt ar idntifid, th appropriat individuals ar notifid of th issus and a rasonabl improvmnt plan is dvlopd. This will b accomplishd through th following: Communicat individual improvmnt opportunitis to th appropriat dpartmnt chair, who, with th assistanc of th MSQC Chair, dvlops an improvmnt plan if ncssary. Communicat systm improvmnt opportunitis to th appropriat hospital committ. Track rsponss and improvmnt plans Rviw th improvmnt plan on a schduld basis Rport to th MEC rgularly rgarding actions takn to improv car and any cass whr action was not takn whn rqustd or actions ar prcivd to b inadquat. Masurmnt Systm Managmnt Mak rcommndations to th MSQOC rgarding rqusts to th quality managmnt dpartmnt for additions or dltions to indicators, critria or focusd studis for valuating physician prformanc. At last annually rviw th indicators, scrning tools and rfrral systms for ffctivnss in collaboration with th mdical staff dpartmnt chairs and rcommnd changs to th MSQOC. Mak rcommndations to th MSQOC, rgarding th appropriat contnt for physician prformanc fdback rports No changs can b mad to th chartr and policis without approval of th MEC. Mmbrship Th Mdicin MSQC will b comprisd of svn to nin (7-9) mmbrs with at last on rprsntativ mmbr from ach of th following spcialtis: Intrnal Mdicin, Family Mdicin, Cardiology, Pulmonary/Critical Car Mdicin, Gnral Surgry and Emrgncy Mdicin. Othr mmbrs may b appointd at larg. Physicians from othr spcialtis may b invitd to th mting as ndd. Th MSQOC Chair, a nursing rprsntativ and appropriat Quality support staff ar x-officio mmbrs without a vot. At larg mmbrs of th MEC may attnd as gusts. Th Committ mmbrs will b appointd by th Prsidnt of th Mdical Staff basd on th rcommndations from th Committ Chair and approvd by th MEC. Rprsntativ mmbrs will srv for a thr yar trm xcpt for initial committ mmbrs. Th initial committ will hav staggrd trms with a third of th mmbrs assignd initial trms of on yar, a third assignd initial trms of two yars and a third assignd initial trms of thr yars. Mmbrs may srv up to two conscutiv trms and ar ligibl for rappointmnt to th committ aftr on yar. Th Chair of th MSQC will b appointd by th Prsidnt of th Mdical Staff, and approvd by th MEC for a trm of on yar. To b ligibl for appointmnt as Chair, th mmbr must hav srvd on th committ at som point in tim for at last on yar, xcpt for th first Chair of th committ. Th Chair may srv an unlimitd numbr of conscutiv trms as long as thy ar ligibl to b committ mmbr. Th Chair will b an x-officio mmbr of th MEC. Committ mmbrs will b xpctd to attnd at last two thirds of th committ mtings ovr a twlv month priod to maintain mmbrship. Committ mmbrs will b xpctd to participat in

15 appropriat ducational programs providd by th Hospital or Mdical Staff to incras thir knowldg and skills in prforming th Committ s rsponsibilitis. Mtings Th committ will mt at last 10 tims pr yar. A quorum for purposs of making cas dtrminations will b basd on th prsnc of 50% of th voting committ mmbrs at a rgularly schduld mting. A majority will consist of a majority of voting mmbrs prsnt. Rporting Th Committ will rport to MSQOC/Mdical Excutiv Committ at last 10 tims pr yar.

16 Surgry Multi-Spcialty Quality Committ (MSQC) Chartr Goals Establishmnt of a multi-spcialty committ for improving physician prformanc on an individual and aggrgat lvl to accomplish th following: 1 Improv patint outcoms by pursuing and maintaining xcllnc in physician prformanc 2 Crat a cultur with a positiv approach to physician pr rviw 3 Promot fficint us of physician and quality staff rsourcs 4 Assist in providing accurat and timly prformanc data for physician fdback and rappointmnt 5 Support mdical staff ducational goals to improv patint car Scop Th MSQC will b rsponsibl for valuating and improving physician prformanc for th surgical spcialty aras undr its scop undr th ovrsight of th Mdical Staff Quality Ovrsight Committ (MSQOC) for th six Comptncis as dscribd th Pr Rviw Policy and Mdical Staff Expctations.: Th following spcialty aras ar undr th scop of th Surgry MSQC: Gnral Surgry Orthopdic Surgry Cardiothoracic Surgry Vascular Surgry Urology Ophthalmology Otolaryngology Plastic Surgry Nurosurgry Trauma/Critical Car Pdiatric Surgry OroMaxilloFacial Surgry Dntistry Bariatric Minimally Invasiv Colo-Rctal Surgry Ansthsiology Th following aras ar considrd outsid th Committ s scop: o Individual physician bhavior incidnts will b th rsponsibility of th MEC. o Routin concurrnt aspcts of physician rsourc us will b managd through th Utilization Rviw procss. Pattrns and trnds data will b initially addrssd by th MSQC. o Policis rquiring mdical staff approval for Blood Us will b rfrrd to th MEC for approval. Th MSQC will prform pr rviw rlating to th us of blood or blood products. o Formulary and mdication policy issus rquiring mdical staff approval will b addrssd by th Drug Thrapy Managmnt Committ and rfrrd to th MEC for approval. Th MSQC will prform pr rviw rlating to th us of mdications rlatd to physician car. o Halth Information Managmnt systms issus will b addrssd and issus rlatd to physician complianc rlatd to documntation critria and rcord compltion will b addrssd by th Mdical Rcords Committ. Physician prformanc indicators for HIM issus will b dtrmind by th MEC. o Crdntialing and privilging is th rsponsibility of th Mdical Staff Dpartmnt Chair and th Crdntials Committ. Rsponsibilitis Evaluation of Individual Cass

17 Initial rviw of all cass of sufficint complxity of managmnt or sriousnss of outcom rquiring physician pr rviw basd on cass idntifid by Rviw indicators, ongoing dpartmntal audits or through rfrrals to th Quality and Outcoms staff for th spcific clinical conditions as dfind in th scop of th committ. Obtain rviws and rcommndations from spcialists on th mdical staff or othr MSQCs whn rquird. Communicat with th physician involvd with th cas to obtain input prior to making dtrminations whn opportunitis for improvmnt may xist. Mak rcommndations rgarding individual or Hospital Systm PI opportunitis for improvmnt basd on individual cas rviw. Evaluation of Rat and Rul Indicators Prform rgular rviw of advrs outlirs from aggrgatd rsults of Rul indicators and of advrs pattrns, trnds and outlir status for Rat indicators rlvant to all dimnsions of physician prformanc for th spcific clinical conditions as dfind within th scop of th committ. Th purpos of this rviw is to dtrmin if additional analysis or focus studis ar ndd. This function may b dlgatd to an individual mmbr of th committ or to a subcommitt. Idntify individual or Hospital PI opportunitis for improvmnt and dtrmin if additional analysis or focus studis ar ndd. Ovrsight of Othr Mdical Staff Physician Prformanc Evaluation Committs Th vast majority of initial rviw of individual cass, along with rul and rat indicator rsults, will b prformd by th appropriat MSQC. mdical staff dpartmnts that wish to mt for purpos of M & M rviw for ducational purposs may also do so if thy wish. Such discussions will b considrd part of th mdical staff quality function and ar protctd from discovry as long as th appropriat policis and procdurs ar followd. Howvr, som mdical staff dpartmnts or committs will continu to prform spcific functions ithr as a quality control mchanism or to rviw of spcific procsss and outcoms as appropriat for dpartmntal prformanc improvmnt and ducation. Th MSQOC will hav ovrsight of th procss usd to prform this rviw and th indicators slctd by th spcialty. For Rul or Rat indicators dtrmind by th MEC as rportabl to th mdical staff, th dpartmnt will rport th rsults to th MSQOC. Th dpartmnt or th group will rfr to th quality offic any cas mting mdical staff Rviw indicator critria for initiation of th cas rviw procss by th appropriat MSQC. Th following aras will prform this function as dscribd blow: Pathology: Th Pathology Dpartmnt will prform rviw of surgical pathology or cytology slids intrprtd by pathologists with th aggrgat findings rportd to MSQOC. Cass rsulting in significant chang in tratmnt, or significant advrs outcoms potntially rlatd to physician car, as dfind by Rviw indicators du to misintrprtations or missd findings will b rfrrd to th quality offic to initiat th MSQC pr rviw procss. Radiology: Th Radiology Dpartmnt (including Diagnostic imaging, Intrvntional Radiology) will prform rviw of radiologic imags intrprtd by radiologists with th aggrgat findings rportd to MSQOC. Cass rsulting in significant chang in tratmnt, or significant advrs outcoms potntially rlatd to physician car, as dfind by Rviw indicators du to misintrprtations or missd findings will b rfrrd to th quality offic to initiat th MSQOC pr rviw procss. Emrgncy Dpartmnt: Th Emrgncy Dpartmnt may prform rviw of spcific procsss and outcoms as appropriat for dpartmntal prformanc improvmnt and ducation. Cass rsulting in significant advrs outcoms potntially rlatd to physician car as, dfind by Rviw indicators, will b rfrrd to th quality offic to initiat th MSQC pr rviw procss. Ansthsia: Th Ansthsia Dpartmnt may prform rviw of spcific procsss and outcoms as appropriat for dpartmntal prformanc improvmnt and ducation. Cass rsulting in significant advrs outcoms potntially rlatd to physician car as, dfind by Rviw indicators, will b rfrrd to th quality offic to initiat th MSQC pr rviw procss. Trauma: Th Trauma Committ will continu to prform its functions undr th rquird ACS standards. Cass rsulting in significant advrs outcoms potntially rlatd to physician car as

18 dfind by Rviw indicators will b rfrrd to th quality offic to initiat th MSQC pr rviw procss. Hoffman Hart and Vascular Institut: Th Hoffman Hart and Vascular Institut may prform rviw of spcific procsss and outcoms as appropriat for institut prformanc improvmnt and ducation. Cass rsulting in significant advrs outcoms potntially rlatd to physician car as, dfind by Rviw indicators, will b rfrrd to th quality offic to initiat th MSQC pr rviw procss. Improvmnt Opportunitis Th rol of th MSQC is to assur whn opportunitis for improvmnt ar idntifid, th appropriat individuals ar notifid of th issus and a rasonabl improvmnt plan is dvlopd. This will b accomplishd through th following: Communicat individual improvmnt opportunitis to th appropriat dpartmnt chair, which, with th assistanc of th MSQC Chair, dvlops an improvmnt plan if ncssary. Communicat systm improvmnt opportunitis to th appropriat hospital committ. Track rsponss and improvmnt plans Rviw th improvmnt plan on a schduld basis Rport to th MEC rgularly rgarding actions takn to improv car and any cass whr action was not takn whn rqustd or actions ar prcivd to b inadquat. Masurmnt Systm Managmnt Mak rcommndations to th MSQOC rgarding rqusts to th quality managmnt dpartmnt for additions or dltions to indicators, critria or focusd studis for valuating physician prformanc. At last annually rviw th indicators, scrning tools and rfrral systms for ffctivnss in collaboration with th mdical staff dpartmnt chairs and rcommnd changs to th MSQOC. Mak rcommndations to th MSQOC, rgarding th appropriat contnt for physician prformanc fdback rports No changs can b mad to th chartr and policis without approval of th MEC. Mmbrship Th Surgry MSQC will b comprisd of svn to nin (7-9) mmbrs with at last on rprsntativ mmbr from ach of th following spcialtis: Gnral Surgry, Cardiothoracic Surgry, Orthopdic Surgry, Ansthsiology, Critical Car Mdicin, Emrgncy Mdicin and Radiology/Intrvntional Radiology. Othr mmbrs may b appointd at larg. Physicians from othr spcialtis may b invitd to th mting as ndd. Th MSQOC Chair, a nursing rprsntativ and appropriat Quality support staff ar x-officio mmbrs without a vot. At larg mmbrs of th MEC may attnd as gusts. Th Committ mmbrs will b appointd by th Prsidnt of th Mdical Staff basd on th rcommndations from th Committ Chair and approvd by th MEC. Rprsntativ mmbrs will srv for a thr yar trm xcpt for initial committ mmbrs. Th initial committ will hav staggrd trms with a third of th mmbrs assignd initial trms of on yar, a third assignd initial trms of two yars and a third assignd initial trms of thr yars. Mmbrs may srv up to two conscutiv trms and ar ligibl for rappointmnt to th committ aftr on yar. Th Chair of th MSQC will b appointd by th Prsidnt of th Mdical Staff, and approvd by th MEC for a trm of on yar. To b ligibl for appointmnt as Chair, th mmbr must hav srvd on th committ at som point in tim for at last on yar, xcpt for th first Chair of th committ. Th Chair may srv an unlimitd numbr of conscutiv trms as long as thy ar ligibl to b committ mmbr. Th Chair will b an x-officio mmbr of th MEC. Committ mmbrs will b xpctd to attnd at last two thirds of th committ mtings ovr a twlv month priod to maintain mmbrship. Committ mmbrs will b xpctd to participat in appropriat ducational programs providd by th Hospital or Mdical Staff to incras thir knowldg and skills in prforming th Committ s rsponsibilitis.